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Complications from Use of Sodium Hyaluronate (Healonid) in Anterior Segment Surgery

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Complications from Use of Sodium Hyaluronate (Healonid) in Anterior Segment Surgery Br J Ophthalmol: first published as 10.1136/bjo.66.11.714 on 1 November 1982. Downloaded from British Journal ofOphthalmology, 1982, 66, 714-716 Complications from use of sodium hyaluronate (Healonid) in anterior segment surgery S. P. B. PERCIVAL From Scarborough Hospital SUMMARY Sodium hyaluronate brings an important new advance to several techniques in ophthalmic microsurgery. Its use in 226 primary lens implantations is described, and it has been found to be safe and beneficial to both surgeon and patient. Apart from a one day rise of intraocular pressure, obviated by the routine use of timolol maleate or acetazolamide, it has been found in the dosage used to be free from complication. Sodium hyaluronate was first used in ophthalmic and in the field of lens implantation' '3 (anterior surgery as a vitreous substitute more than 10 years chamber manipulation, protection of endothelium, ago' when its properties were shown to be elastic, synechiolysis, iris suturing, and to maintain anterior highly viscous, yet nontoxic, noninflammatory, and chamber depth for secondary procedures such as copyright. nonantigenic.2 More recently Balazs, Miller, and keratoplasty and filtration surgery). Healonid may Stegmann introduced its use into anterior segment also be used in retinal detachment surgery'415 (for surgery.35 The 1% solution (Pharmacia UK Ltd, internal tamponade). Healonid) is at least 400000 times more viscous than This communication seeks to assess the possible aqueous yet will pass through the fine Rycroft complications that may be attributed to Healonid in cannula. It is totally transparent, and because of its the field of primary lens implantation. high molecular weight it is nonosmotic. Because of these properties and the fact that it will maintain Material and methods http://bjo.bmj.com/ anterior chamber depth when air may not, it has been described as the ideal medium for closed chramber Three hundred and thirty-four consecutive lens surgery.6 replacements were performed during the 29 months The particular assets of Healonid are that it will commencing January 1980. 244 followed planned allow complex surgical manipulation in the anterior extracapsular nucleus extraction (as described chamber, improving visibility while protecting the previously6) with an age range 39-88, mean 73 years; corneal endothelium and surrounding tissues from 90 followed intracapsular cryoextraction after on September 25, 2021 by guest. Protected the trauma of surgical instrumentation. It may also be zonulysis, with an age range 56-94, mean 77 years. used to aid atraumatically the cleavage of iris Healonid was used for every case when it was synechiae or other adherent tissues. Thus Healonid available. For standardisation, between 0-2 ml and has a place in the field of trauma'8 (synechiolysis, 0-3 ml was used per eye whether or not the particular extraction ofcorneal splinters penetrating the anterior eye needed it. There was therefore no patient chamber, anterior segment reconstruction), in selection for the use of Healonid. No attempts were keratoplasty459 (both for donor and recipient eye to made to aspirate Healonid at the end of surgery. It protect endothelium), in filtration surgery' (to prevent was used in a total of 226 eyes to deepen the anterior flat anterior chamber and hypotonia), in extra- chamber prior to lens implantation. Of these, 164 capsular cataract extraction'6 (during capsulectomy followed extracapsular extraction when it was also and to protect endothelium from a hard lens nucleus), used to maintain the anterior chamber during capsu- lectomy and inserted to provide a cushion between lens Correspondence to S. P. B. Percival, FRCS, Department of nucleus and cornea during extraction, and 62 Ophthalmology, Scarborough Hospital, Scarborough, North followed cryoextraction, 46 ofwhich also necessitated Yorkshire. an iris suture, placed as described by the author'2 714 Br J Ophthalmol: first published as 10.1136/bjo.66.11.714 on 1 November 1982. Downloaded from Complications from use of sodium hyaluronate (Healonid) in anterior segment surgery 715 Table I Postoperative ocular hypertension in 334 eyes Eves First day Mean IOP (mmHg) IOP>30 mmHg 5 mm>preop. 1st day 3rd day 108 Controls 11(10%) 24(22%) 18-9 15-7 54 Healonid 17 (31%)** 31(57%)** 25 6 15-5 109 Healonid+acetazolamide 8 (7%)** 38 (35%)* 19-7 14-4 63 Healonid+timolol 7 (1 1%)* 20 (32%)* 20-0 14-2 IOP=intraocular pressure. *p<O-0; **p<0-OOl. under Healonid with the chamber closed. There was flow by 33% and tab. acetazolamide 250mgby27%.'7 only one case of aborted lens implantation during the Of the 109 eyes in the present study receiving 29 months, this being for reasons of vitreous loss. Healonid and routine postoperative acetazolamide Postoperative routine included careful slit-lamp the mean first-day intraocular pressure was 19-7 examination by the author on the first, third, and mmHg, and only 7% ofreadings were over 30 mmHg. fifteenth postoperative days and more frequently Of the 63 eyes receiving Healonid and routine timolol when necessary. Raised intraocular pressure was the corresponding figures were 20-0 and 11% treated with topical timolol maleate or systemic respectively. acetazolamide or both in combination. However, These findings confirm the value of acetazolamide following the initial trial with 54 cases, in order to and timolol in reducing aqueous secretion, and Table obviate further ocular hypertension, 2 subgroups of 1 also shows that by the third postoperative day there patients receiving Healonid were made: (a) during was little difference in mean intraocular pressure copyright. 1981 109 patients were given routine intramuscular between the different groups, the marginally higher acetazolamide 500 mg 4 hours after completion of mean pressure found in controls being explained by surgery followed by tablets 250 mg q.d.s. for 2 days; the fact that these eyes were less likely to have been (b) during 1982 63 eyes received timolol maleate offered treatment. 0-25% drops on completion of surgery followed by No significant difference was found between intra- b.d. application for 2 days. Particular attention was capsular and extracapsular eyes (Table 2). There paid to development of uveitis, wound healing, and were no cases of pupil block glaucoma among the ocular hypertension. groups receiving Healonid. http://bjo.bmj.com/ POSTOPERATIVE OCULAR HYPERTENSION Discussion Healonid leaves the anterior chamber by way of the aqueous outflow channels,'6 but the viscosity has to UVEITIS be reduced by dilution with aqueous before this On the first day slit-lamp examination often gives the hydrophilic substance may run through the trabecular appearance of a plastic anterior uveitis in an eye meshwork. Intraocular pressure may rise therefore if containing Healonid. However, this is due to the excessive amounts of Healonid remain in the anterior presence of Healonid holding cells in suspension. on September 25, 2021 by guest. Protected chamber at the end of surgery. Flecks of blood may also be seen held in suspension One hundred and eight eyes did not receive due to rouleaux caused by altered electrostatic charge Healonid or any routine ocular hypotensive. These on red blood cells. These appearances vanish by the acted as controls (Table 1). Of 54 eyes initially third day and do not require specific treatment. 7% of receiving Healonid (all were extracapsular extractions) 57% showed a rise of intraocular pressure 5 mm or Table 2 Incidence ofraised intraocularpressure onfirst more than the preoperative level. The first day postoperative day (the initial 54 extracapsular eyes receiving applanation was over 30 mmHg in 31% and the mean Healonid are excluded) intraocular pressure was 25-6 mmHg compared with IOP>30 mmHg 5 mm>preop. 18-9 mmHg in the control group. Controls28IC 3(11%) 5(18%) Results 80 EC 8(10%) 19(24%) Healonid 62 IC 6(10%) 26(42%) IIOEC 9(8%) 31(28%) In a double-blind trial on 21 normal subjects guttae timolol 0-5% has been shown to reduce the aqueous IOP=intraocular pressure. IC=intracapsular. EC=extracapsular. Br J Ophthalmol: first published as 10.1136/bjo.66.11.714 on 1 November 1982. Downloaded from 716 S. P. B. Percival Healonid eyes and 8% of controls were recorded as References having a more severe uveitis than is expected during I Algrere P. Intravitreal injection of high molecular weight the first postoperative week, but there were no cases hyaluronic acid in retinal detachment surgery. Acta Ophthalmol of hypopyon or of developing keratic precipitates. (Kbh) 1971; 49: 975-7. There were no cases of spluttering hyphaema or of the 2 Balazs EA, Freeman MI, Kloti R. Meyer-Schwickerath G, uveitis-glaucoma-hyphaema (UGH) Regnault F, Sweeney DH. Hyaluronic acid and replacement of syndrome. vitreous and aqueous humour. Mod Probl Ophthalmol 1972; 10: 3-6. WOUND HEALING 3 Balazs EA, Miller D, Stegmann R. Viscosurgery and the use of There were no eyes in which delayed healing or Na-hyaluronate in intraocular lens implantation. Presented at the International Congress and First Film Festival on Intraocular lens improper apposition could be attributed to Healonid. implantation. Cannes, France, May 1979. A disadvantage of Healonid is that at the end of 4 Miller D, Stegmann R. Use of Na-hyaluronate in anterior surgery it is more difficult to assess whether a wound is segment eye surgery. Am Intraoc Implant Soc J 1980; 6: 13-5. water-tight than when the anterior chamber is 5 Pape LG, Balazs EA. The use of Na-hyaluronate in human anterior segment surgery. Ophthalmology 1980; 87: 699-705. reconstituted purely with salt solution. This is of 6 Percival SPB. Protective role of Healon during lens implantation. particular importance during keratoplasty,9 and Trans Ophthalmol Soc UK 1981; 101: 77-8. alternative methods of reconstituting the anterior 7 Stegmann R. Communication to UK Intraocular Implant chamber should be preferred during the final phases Society, Southend, England, May 1981.
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